While I'm not sure how that will play out in prime time, certainly the success of shows like "Unwrapped" and "Have Fork, Will Travel" demonstrate that the gastronomic-themed network isn't afraid to take chances.

As previously noted, we do get quite a bit of email from various folks ("regular" readers, home office critters, and sometimes even trolls), but the other day I received a phone call from a distant land, one which poses some interesting challenges. I post it here in the hopes that one or more of our readers will have some solutions to share.

A couple of days ago, I received a call from Sweden. The caller was a 37 year old young lady pregnant with her first child. She and her husband plan to move to Florida in the next few weeks, and has been unsuccessful in her quest to find health insurance.

Small wonder.

She kept hitting brick walls until she googled "special risk insurance," and found us.

Very cool.

But also very challenging.

Here are the facts:

Sandra is a 37 year old female, 4+ months pregnant. Dual citizenship (US & Sweden), but her husband is a Swedish national. She works for a Swedish company, and will basically be a manufacturer's rep once she gets here. She could potentially qualify for a one-life group, if she ends up in a state where that's relevant. This past summer, she and hubby bought a home in Florida, but she could also land in either North Carolina or Tennessee.

Hey, if it was easy, anyone could do it!

She may also qualify for Medicaid (based on the pregnancy), but that seems a bit murky. I also directed her to the Coverage for All site (in the sidebar) in the hopes that there might be something relevant there.

But what I'm really counting on is the goodwill and immense knowledge-base of our readership.

Unfortunately, it seems to be a simple matter of education; when folks truly understand the tremendous benefits, and relatively low risk, of participating, FSA's become more attractive.

But who, exactly, is going to provide that education?

And some critics (myself included) believe that the major problem with these "use it or lose it" arrangements is that they encourage more health care spending, which in turn drives up costs. Others (myself not included) complain that they "simply encourage overspending on discretionary medical care, at a cost to taxpayers."

Wednesday, November 28, 2007

Master wonk Dr Roy Poses hosts this week's edition of the Health Wonk Review. It's chock full of interesting and insightful posts on health care policy and polity, with helpful summaries of each post.

As regular IB readers know, we are major proponents of transparency in health care, including little things like "does this procedure work, and is it really necessary?" Over at Gooznews, blogger Merrill Goozner [ed: what a cool name!] takes a look at the latest cancer screening test being touted by Medicare and the VA, and asks "(d)oes screening actually save any lives?" The answer may surprise you.

As I've noted before, I have a little sticker on my phone as a constant reminder to always do what I think is in my clients' best interest (not that I need constant reminding, but it keeps me humble). Today I had another opportunity to take it for a spin, and I'd like to share that with you. A caveat, however: the story you're about to read is true, the names have been changed to protect private information, and I share it with you as an example of how I believe most professional agents would handle the same circumstances.

The gentleman who founded this agency almost 40 years ago is semi-retired, but keeps his hand in (mostly so his wife has an excuse to get him out of the house). One of his friends and long-time clients called him with a problem, and he referred this gentleman to me for assistance.

It seems that this gentleman, we'll call him Tom, has a 55 year old daughter, Susan. Susan was widowed some 20 years ago, and raised her two children by herself. The eldest has recently married and moved away to another city, and the youngest is in college away from home, as well. She has found herself becoming more and more depressed, and has found (as so many have) solace in a bottle. This has reached the point that her employer had to let her go this past summer, but continued to pay for her health insurance through the end of this year. At that time, she's on her own; worse, because of her health history (which include the alcoholism and other issues), she is uninsurable in the "regular" market.

I would like to point out that she chose to adopt that bottle, and that most of her other issues stem from that decision. We are all responsible for the decisions that we make.

In the event, I agreed to meet with her, primarily because of that sticker, but also out of loyalty to the retired gentleman. I was also intrigued by some of the side issues, which included an employer exemption from COBRA compliance. Something not widely known is that some organizations aren't required to offer COBRA continuation even though they might otherwise fit the requirements. She had worked for one such, so COBRA was not an option.

Believe it or not, there were others.

One was the state-mandated guaranteed option route. This is the same plan one would buy once one had exhausted COBRA (were it available and elected). The benefits of this plan were the low qualification threshold (doesn't get much easier than "guaranteed issue") and the fact that it would cover her pre-existing conditions. On the down side, it's rather mediocre coverage, but it is expensive. For Susan, the rate would be well over $1,000 a month.

I understand and believe in the value of insurance. But I also try to live in "the real world." So I absolutely understand if someone says "12 thousand dollars a year?! Plus deductibles and co-insurance? Are you kidding?!" So I can certainly understand someone who decides to roll the dice. And I can't say that I blame them, or even disagree.

Heresy!

Not at all. Insurance is about risk assessment ("I'm uninsurable") and risk management ("this stuff is expensive!"). If one can't justify the premium based on the cover, then that's a legitimate conclusion.

So I also proposed a limited benefit (or mini-med) plan as an alternative to the state-mandated one. My thinking was that it would serve to mitigate the damage should there be a large claim. Again, it's a question of risk management.

Finally, I also printed out the Ohio grid from Coverage for All (on our sidebar). The idea was that, even if she decided not to buy any insurance to offset her increased risk, at the very least I could help her find some way to soften the blow as she received the treatment she needs.

This is a sad situation, with no real "happy ending." But I was awfully proud to have been able to help in some small way.

Okay, I need to work on that title, but here's the gist:If we agree that health insurance has more in common with Property/Casualty than Life insurance, then perhaps we can learn a lesson from our friends in the Sunshine State:

And that's worked out pretty well: Citizens is now the biggest writer of property insurance in Florida, eclipsing even our friends The Good Neighbors.

In fact, Citizen's has become so successful that it currently has over $400 billion (yes, billion with a "b") in liabilities.Which is only a problem insofar as it's currently collected something like $3 billion in premiums.

Ooops.

But that's not really a problem, you see, because -- worst case scenario -- if there is a devastating storm that wipes out Citizens' (and you just have to love the irony of that name here) meager assets, all they have to do is go back to the actual citizens (note the lower case "c") and make them pony up.They can do that, you see, because they've got the power of the government behind them.

Sweet.

Until you start calculating the costs: "Andrew, in 1992, caused $23 billion in damage," or about 7 years worth of premiums. And that was 1992 dollars. Do the math.

Now, what does this have to do with health insurance? Well, it seems to me that this P&C scheme quite accurately models what we've seen proposed in the way of gummint-run health insurance (and please note the very purposefully chosen terms). That is, the government decides what's (and who's) covered, sets the premiums, and (if they're too low), comes back for more (see Bob's post below). With the power of the federal government.And what happens if (or when) there's a major problem (MRSA, anyone?)?

You could see it coming a mile away. The Mass mandate for employers to provide health insurance was sure to see some who would opt out.

And why not? The penalty for failure to provide health insurance for their workers?

$295 . . .

Still, I am surprised that only 500 firms chose the penalty over the coverage. Frankly, I thought it would be much higher.

Of course the participation and contribution requirements were a bit on the lean side.

Companies with 11 or more full-time-equivalent employees face the penalty unless 25 percent of their employees buy company-subsidized insurance or the company offers to pay at least one-third of employees' individual premiums.

Compare this to a typical group plan where employers are required to pay 50% of the employee premium and maintain 75% participation of the eligible employees.

But the 500 who failed to comply is only part of the picture.

the state required about 62,000 companies with eight or more employees to report by Nov. 15 whether they met the insurance standard. Nearly 44,000 filed, but more than half were too small to face the coverage requirement and almost all of the rest said they already provided insurance. So far, 518 have agreed to pay the penalty.

So let me see if I have my math correct.

62,000 firms had 8+ employees.

44,000 filed.

Half (22,000) were exempt under the law because they did not meet the minimum number of employees for required coverage.

Seems to me like the real number of employers who are not providing health insurance is more like 22,518 including the 518 who opted to pay a penalty.

"The Romney administration definition . . . has permitted many employers providing little or no coverage to their workers to escape fair share responsibility,"

Paying their "fair share". I hate that phrase.

"For example, if I offer to pay one-third of the premium and none of my employees take up the offer, I escape liability under the law even if I'm not covering anybody.

So in other words, government intrusion into the private sector isn't punitive enough . . . yet.

"This means that taxpayers are carrying and will carry a larger-than-anticipated burden,"

This guy must be one of those who think that employer paid premiums come from thin air. Employers suddenly, as if by magic, find the funds to pay for a government mandate without raising prices to their customers.

Did anyone study Economics 101 in school?

the Legislature had estimated that the "fair share" penalty on businesses would bring in $45 million

Extra credit for using "fair share" and "penalty" in the same sentence.

But the state did not collect any money last year, and the administration of Governor Deval Patrick had already downgraded the revenue estimate to $24 million for this year.

Oops! Sounds like a $21M short fall in revenues. Oh well, this is government we are talking about, not the private sector. Everyone knows the government has unlimited access to funds.

Tuesday, November 27, 2007

About a month ago, Mike wrote about the disconnect between reality and prescription drug co-pays. Under Mike's current health plan, if a med costs $10, and the co-pay is $15, he actually has to part with the extra $5 if he uses his card. So of course, he simply says "nope" when asked about insurance, and gets that med for $10. He (and apparently lots of others) have also found the $4 deals (WalMart, Target, etc) to be a boon in this regard, as well.

One of our faithful readers took issue with Mike's assertion that he'd have to pay the full co-pay even if the med actually cost less. This reader (who wishes to remain anonymous, but for whom I can vouch credibility) wrote to let us know that his company, United Healthcare, generally doesn't ding their members in this way:

"I have now confirmed that UnitedHealthcare (my employer) IN FACT DOES only assume member responsibility up to the contracted cost of a covered service for BOTH medical and pharmacy claims. In short, we do not attempt to charge members a full copay for covered services like those involving $4 generic drugs at Walmart and Target when the contracted rate is less than the copay on covered services."

He adds that their most recent pharma contract language says:

"For Prescription Drug Products at a retail Network Pharmacy, you are responsible for paying the lower of:

• The applicable Copayment and/or Coinsurance or

• The Network Pharmacy's Usual and Customary Charge for the Prescription Drug Product."

Which would seem to indicate that under those plans, if the scrip was $10, you'd pay $10.

Of course, these all apply to commercial, insured plans, not ERISA (self-funded) ones. Generally, ERISA plans can include pretty much any language the employer wants, which means that the minimum co-pay amount charge could be required in such a plan.

I'd really like to Thank our anonymous source, and would challenge other carriers (we know you read us!) to chime in.

Dr Prudence, writing at her eponymously named blog, presents an outstanding 'Rounds this week. This marks her debut hosting GR. She starts with her five favorite (and, we're proud to say, our entry claims the Top Spot), and then another 28 entries, all are categorized and include helpful context.

Why would a hospital work with a finance company? Because it is more humane than breaking your other leg to get payment for services rendered.

And there is this . . .

Collecting from "self-pay" patients like Dial has long been the bane of medical administrators. When they don't get paid immediately, hospitals typically recover around 10¢ on the dollar owed, even when they hire collection specialists.

How many businesses could survive by collecting only 10% of the revenue owed? Suppose your boss said your paycheck would be cut by 90% until they can catch up on revenues. How well would that go over?

So hospitals and clinics are bringing in more sophisticated help. They are transferring patient accounts wholesale to finance experts, banks, credit-card companies, and even private equity firms.

This comment caught my eye as it runs contrary to the usual thought process.

Among hospitals, nonprofits like Hot Spring County Medical Center are more likely than for-profit rivals to join forces with finance firms. Fewer nonprofits have effective in-house collection departments,

Not for profit hospitals are jumping on the bandwagon. Interesting development.

"The world of $5 sent to the hospital and they will never send me to collections, never sue me—that world has gone away,"

It is time for this old wives tale to go away. Medical providers need cash to continue to serve their communities. If patients are going to act irresponsibly, when they have the means to cover their bills, then it is time for them to share the pain.

Hardly a week goes by that I do not talk to someone without insurance who is mostly tire kicking. They are healthy enough to qualify and certainly have the income but they feel they don't need insurance "because I am not sick". If they can pick up a plan to cover their doc & meds for around $60 per month they will buy. Otherwise they will just pass and "pray they don't get sick".

Well I hope they don't get sick either. When they do I will end up paying their bill while they stiff the hospital & docs.

Unless of course the hospital decides to sell their account to a finance company.

Monday, November 26, 2007

And it's a doozy! Host Blain Reinkensmeyer, blogging at Stock Trading To Go, has this week's passel of personal finance posts, all helpfully categorized and summarized. There's even an interesting factoid for each category (did you know that Bill Gates makes $30 million every night - in his sleep?!).

This week's Carnival offers a Top Five, and our friend SVB from The Digerati Life has a helpful and timely post on how to be a safe, careful consumer. Some good advice, especially at this time of year.

Beware the pusher man. Not the one lurking in the shadows, or hanging around school yards. This one comes in a tailored suit and attends luncheons & cocktails.

Doc's are heavily recruited to push drugs. Some estimates say 25% of docshave a sideline business promoting meds.

So what's wrong with that? Doc's are being squeezed by managed care to see more patients and accept lower reimbursements. Is there anything wrong with recruiting doc's as pitch men (and women)?

What do you really know about your doc and the meds they push? Are they a decile 6 doc?

I received faxes before talks preparing me for particular doctors. One note informed me that the physician we’d be visiting that day was a “decile 6 doctor and is not prescribing any Effexor XR, so please tailor accordingly. There is also one more doc in the practice that we are not familiar with.” The term “decile 6” is drug-rep jargon for a doctor who prescribes a lot of medications. The higher the “decile” (in a range from 1 to 10), the higher the prescription volume, and the more potentially lucrative that doctor could be for the company.

Some docs are trigger happy when it comes to meds. Is it because they work or is there some other motivation?

How much information is gathered on your doc's scripting and how is it used? You may be surprised.

they received printouts tracking local doctors’ prescriptions every week. The process is called “prescription data-mining,” in which specialized pharmacy-information companies (like IMS Health and Verispan) buy prescription data from local pharmacies, repackage it, then sell it to pharmaceutical companies. This information is then passed on to the drug reps, who use it to tailor their drug-detailing strategies.

Guess who else is in the food chain.

The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.

So what is the end result?

You may be taking meds that you do not need? Or perhaps your overall health (and wallet) could be better served with a different, possibly lower cost, med.

Are you taking additional drugs to offset the side effects of your primary medication?

Consumers are just as much to blame as the drug companies. More often than not patients fail to question their doc about prescribed meds. Is this the best med for you or simply one that comps your doc more than another?

Does the pusher man in your life have a sheepskin on his wall?

UPDATE: We asked fellow MedBlogger Dr John Ford about this issue, and he replied that it's "very real, very common, and very legal."

Marietta, Georgia based Matriahas discovered there is money to be made in providing a reminder service. With clients like AT&T, Cisco, Coca-Cola, Humana, Proctor & Gamble and more it makes one wonder.

The goal of disease-management firms is simple.

The sickest 20 percent of the population accounts for 80 percent of health care costs.

The program figures by managing the habits of those who are most ill — by phoning them with reminders and tips — health care costs could be radically reduced by keeping thousands out of high-priced emergency rooms and hospitals.

A simple business model.

Isn't this what mom used to do?

Apparently we have a host of people who never listened, and that is a good thing for Matria.

Thursday, November 22, 2007

Bob, Bill, Mike and I extend to all our readers and guests a wonderful, joyous, and safe Thanksgiving.

And building on Bob's post below, there's a concrete way to say Thank You to those who spend the holiday guarding the freedoms for which we're so grateful: most cell phone companies are participating in the Giving Thanks Campaign, through which you can text your own, personal Thank You to our men and women in uniform. Just text your message to 89279 and bring a smile to a soldier's face.

Wednesday, November 21, 2007

Give thanks . . . for the things in your life that really matter. Rich is not what you have, but who you have beside you.

Give thanks . . . for those you love and those who love you. There are people who you have never met but still they have a love for you. They care so much about you they are willing to put themselves in harm's way to protect you.

Give thanks . . . for those who serve in the military as well as emergency responders. Each one of them is a husband, wife, son, daughter, father, mother or friend of someone. Each of them have someone who cares about them.

Give thanks . . . for those who attend to your health needs when you are ill or injured. Their skill and compassion is just a part of the healing process.

Give thanks . . . for the good things in your life. Everything has a purpose. The good things are a reminder of how blessed you are. But bad things happen for a purpose as well, if for no other reason than to make you appreciate the good in life.

Give thanks . . . for adversity for it is from adversity that we become strong. General Douglas MacArthur penned a poem I gave to my son long ago. One of the great lines reads, "Lead him, I pray, not in the path of ease and comfort, but under the stress and spur of difficulties and challenge. Here, let him learn to stand up in the storm; here, let him learn compassion for those who fall."

Give thanks . . . not just during this season, but every day. Life is a gift. Enjoy it to the fullest and do not miss a single moment.

Well why not? When "someone else" (i.e. the taxpayer) is picking up the tab, it's not too difficult to see the attraction. But that $147 mil is only the beginning; we have to wait for the second page of the article to learn that the true liability is over $600 million, more than 4 times the current shortfall.

And since the plan does absolutely nothing to control the cost of health care, expect those numbers to climb even (ever?) higher.

One bright spot: by treating the various states as independent laboratories for these experiments, we're able to contain the damage, yet still learn a little bit more about which kinds of plans will work, and which ones not so much.

"We would like invite you to participate in a study of health bloggers, "From My Experience to Yours: Taking the Pulse of Health Care Blogs in the Blogosphere," administered by Brown University. The study assesses the use of blogging in the area of health and medicine."

They're targeting "health-related" bloggers; of course, if they truly understood the genre, they'd call us "medbloggers." Still, it's interesting that they're trying to quantify our little corner of the blogosphere.

The survey's hosted by a site called, of course, "SurveyMonkey." It was pretty well done (took me about 5 or 6 minutes to do). They asked questions about how long I'd been blogging, and (more importantly) why. What they didn't ask was also interesting: no questions about blogging for money, or awards, for example. There were some demographic questions (age, household income, etc). They specifically asked if I was Hispanic (I'm not, but my daughter's in Honors Spanish).

At the very beginning, they said this:

"This survey is part of a research study at Brown University of health-related blogs, covering such topics as health policy, research and news, specific illnesses or diseases, and personal experiences of doctors, students, and patients. Our research examines the ways in which blogging has impacted discussion of health topics, information dissemination, and community-building."

The email promised me "a summary of the responses." One supposes that this is remuneration enough.

We take pride in associating with the best talent in the legal world, so we are thrilled to include you as part of this dynamic new platform that features commentary from experts, and gives visitors to the site the ability to interact with the content and one another. Also featured on the site is real-time insurance news, blogs from internal teams at LexisNexis, news about attorneys, firms and insurance companies, plus several delivery options, including RSS feeds, Podcasts and email alerts.

The selection of your blog was made by insurance editors at Matthew Bender and LexisNexis Mealey's Insurance publications as one that can be relied upon to provide its readers with timely review and analysis on insurance and insurance related topics.

We are thrilled and honored to be selected, and just a bit stunned, as well. Thanks to our readers for helping to move us "up a notch."

Monday, November 19, 2007

DeLay claimed that, under the U.S. system, “no American is denied health care”:

Emergency health care is available to anyone, regardless of citizenship or ability to pay.

Observers estimate that anywhere from one to 18 percent of Americans are denied health insurance because of pre-existing health conditions.

Denied health insurance, not health care.

Currently 35 states have risk pools for those who have been denied health insurance. Four states require carriers to issue coverage to anyone who applies, regardless of prior health history. Several states have mandated open enrollment and others have carriers of last resort who must take anyone who applies. All states have HIPAA provisions that allow someone coming off a group plan to obtain coverage.

It apparently doesn't matter if you have glaucoma or not. Just ask your doc for the prescription.

Doctors and patients alike have noticed that eyelash growth is a side effect of a glaucoma drug called Lumigan

Wonder what other "hairy parts" are affected?

Lorrie Klein, a cosmetic dermatologist in Laguna Niguel, Calif., says she started prescribing Lumigan after noticing "beautiful, long lashes" on a patient using Lumigan for glaucoma. Now, Dr. Klein promotes Lumigan on her Web site as "easy to use at home with only a once daily application" for "one to three months to achieve the desired length, and then once weekly for maintenance." She advises patients to use a disposable brush to apply the drug.

Dr. Klein says she feels comfortable prescribing Lumigan because it comes from Allergan, which sells other dermatological drugs and products. Some of her patients, she says, work for Allergan and have told her the company has recruited subjects for a clinical trial of Lumigan for cosmetic use. Dr. Klein notes that Lumigan's safety has been validated by FDA tests. "It's scary to me as a physician that some cosmetic companies are slipping in a prescription drug," she said.

So . . . Dr. Klein has no problem promoting Lumigan for cosmetic purposes, but does have a problem when cosmetic companies want to "slip in" a prescription drug.

Last week, we discussed the curious case of the gentleman who submitted multiple applications to the same carrier, both of which contained fraudulent information. I spoke this morning with the underwriter, and then with the Department of Insurance.

The underwriter is well aware of the facts in this case, because he is the underwriter for both myself and the other agent. We had a rather lengthy conversation, wherein I reiterated that the only correct course of action was to decline both applications for material misrepresentation. He disagreed, but offered no rationale for that decision. He is going forward with the underwriting.

I told him that I had no intention of withdrawing my application, and he responded that it didn't really matter, because the applicant was providing the other agent with an Agent of Record letter. This is a means by which an insured can specify his "official" agent in these matters. At that point, I begged off the conversation before I said something regrettable.

I really had only one option at that point, which was to contact the Department of Insurance, Fraud Division, and discuss this with them. After laying out the whole story, the gentleman from the DOI explained that there really wasn't anything that they could do, and that I had done my due diligence in this matter. Since I had informed the carrier of the fraud (actually, they already knew, I simply confirmed it), there was nothing more for me to do. If the carrier was so inclined, they could notify the state, but that was entirely in their hands.

I explained to the DOI rep that in addition to selling insurance, I'm also a licensed CE provider, and even teach a course on ethics. To which he replied (correctly) that I teach agent ethics, not consumers'. That's really only half right: the course also includes carrier ethics (an oxymoron, of course), but I didn't think that bringing this up would move the ball forward.

At this point, there's really nothing more for me to do with this case. I will not withdraw the application, but I won't pursue it, either. Of course, I now have to rethink my relationship with Carrier C. I have printed out a copy of both these posts and added them to this client's file; in addition, I've sent a note to the underwriter confirming the facts of the case (a copy of which is also in that file).

There are a number of issues that follow from this, of course, and perhaps these would be worth exploring in the comments section. In the meantime, I'll consider the matter closed, and try to move on (although I'm not really sure that I can).

This week's Carnival of Personal Finance is now available at Moolanomy. It includes over 80 posts, in the now-familiar Top-10-then-the-rest format (which, for the record, I really prefer for these larger efforts). The "and the rest" posts are divvied up into helpful categories, and include summaries.

Now, it may not seem like 7 out of 3,000 is that big a deal (after all, it's less than 2/10's of 1%). Of course, it's certainly a big deal for those women who were given the incorrect results, but taken as a whole, it wouldn't seem that significant.

Except for this:

"Then as the situation further evolved, we learned how there were problems with dirt, with 16-year-old machines."

As Bill has noted before, sanitation is not a high priority in these kinds of systems, so it's not necessarily a big surprise that the equipment is ill-maintained. But if the machines are dirty, the folks who run them are filthy:

"(A) surgeon in the hospital had expressed concerns about radiological service as far back as July 2005. He had particularly pinpointed inexperienced staff."

And it gets worse:

"Patients are devastated and are getting it from every angle; overcrowded Accident and Emergency (A&E) departments, patients on trolleys, hygiene problems...we still get calls every day from patients about things as basic as dirty bathrooms, handwashing facilities and towels."

Regular IB readers may recall our IVF "kerfluffle" a few years ago: I fail to see where this process crosses the "medical necessity" threshold, either. It boggles the mind that this procedure costs upwards of $8,000 a pop.

The catalyst, and rationale, behind this sudden burst of medical activity appears to be cultural rather than medical. I have nothing against most religious practices, but I don't see why the taxpayer is required to fund them.

Once in a while, one comes across a particularly well-reasoned post that seems to just pop out of the screen. Perusing our referral log, I noticed a site with which I was not familiar, and clicked over to it.

And wow, am I glad I did.

Although The Happy Hospitalist has only been blogging for about a month, it's clear that he (she?) brings a unique and valuable perspective to the medblog world. In a post dated yesterday (the 15th), we are treated to a comparison of currency values to the delivery of health care. And it makes sense!

By leveraging a brief explanation of how the US dollar is falling relative to the Canadian "Looney," THH is able to demonstrate how Medicare artificially inflates the cost of medical care for everyone.

Some say our health care system is broken. Others say there are problems, but for the most part, it works as well as, if not better than, other systems.

Some say universal care such as exists in other countries is the answer, yet none of them have found a perfect system either. As long as there is a limited supply of resources (medical providers, funds, etc.) stacked against an unlimited demand for services, there will be shortfalls, even in the best systems.

The WSJ recently profiled one such case. The case of Barbara Calderillustrates a combination of factors that collided to create a perfect storm of health care misunderstanding with few answers. Sadly, the health care system as it exists now is akin to the legal system where life moves at a snail's pace absent clearly defined rules that could lead to a resolution.

Front #1, "Mrs. Calder suffers from Ehlers-Danlos Syndrome, a rare genetic disorder". Barbara has a disease that affects 1 in 5,000. Very few doctors have heard of the illness or know how to diagnose and treat it. This can create a problem in any system, regardless of the way coverage is funded.

Storm front #2, even the taxpayer funded systems failed her. "Unaware of the true cause of her symptoms, she applied for Social Security disability benefits in February 2006. Her application was rejected because her disability was deemed not severe enough." Without a diagnosis, Social Security rules called for a denial. Her initial appeal was denied because she still lacked a diagnosis because a "vocational expert for the Social Security Administration argued her joint problems shouldn't preclude her from working because cooking was a "sedentary" profession".

I suppose this "vocational expert" has never spent any time in the kitchen. I cook most of the meals in our family, am not afflicted with a debilitating disease, and can tell you there is nothing sedentary about cooking.

Even when S.S. finally did approve her claim (almost 2 years after she became disabled) she has a two year wait before she can apply for Medicare . . . the government run, taxpayer funded system.

Storm #3 is the managed care system, or as we like to refer to it at InsureBlog, "mangled care". Barbara could not get a consult with a specialist without a referral from a PCP (primary care physician). She could not get special testing (to prove or disprove her illness) without approval from her carrier. Even when diagnosed, she could not get the medicine prescribed by her doctor until she followed protocol by first trying OTC medications.

All of this has been further complicated by periods where she was between coverage. When she became insured again it was under a new carrier with new rules and new providers. Each time she changed plans she had to virtually start over and learn the new rules set by each carrier.

This is a two edged sword.

If Barbara were covered under a so-called universal system (such as Medicare) she would still fall between the cracks. In fact the safety net for disabled persons is a morass of forms, waiting periods and legal shenanigans that result in all but the most diligent from becoming covered. Had Barbara not had a working spouse who was able to obtain coverage through the private funded system she would have dangled by a thread for 4 years before finding any coverage.

Coverage under the privately funded system, while flawed, at least provided some coverage and eventually led to a resolution.

Barbara's story is not over. She will most likely continue to fight private carriers while waiting on Medicare to kick in. Even then her battle will most likely continue. The government funded systems (most notably Medicare) is equally flawed but in different areas.

Her first challenge will be finding a P.C.P. who is willing to accept new Medicare patients. She may have the same issue in finding a specialist who concurs with the diagnosis and is permitted under C.M.S. rules to authorize the necessary treatment.

The combination of a rare disease, taxpayer funded programs and mangled care created a perfect storm of health care collapse. Her case is truly a sad situation and we wish her the best.

At the same time her battle is not over and may not be for a long time. Even if she were to seek "medical asylum" in another country there is no guarantee her treatment will improve. Every system with limited resources vs. unlimited demand has flaws.

No matter where she turns she will most likely find herself slipping through the cracks of an over-burdened health care system that suffers from limited funding.

Mr Knowlin apparently pled guilty this past summer to conspiracy charges. They arose as a result of a "kick-back scheme" relating to coverage he was assigned to secure for a Magnolia State county. In a rather novel turn of events, Mr Knowlin claims that since he did, in fact, secure said coverage, there were no damages, so nothing to be repaid.

First time hostess Maggie Maher hosts this week's assortment of posts on health care policy, funding and tech. Instead of the usual "list of posts" format, though, she weaves disparate posts into an interesting and compelling narrative. Ingenious, and unique.

Kudos, Maggie!

The folks at Workers Comp Insider never fail to impress me with their ability to take a potentially uber-wonky subject and make it accessible to the rest of us. This week's HWR features such a piece, written by WCI's Jon Coppelman, about an otherwise model employee fired for tardiness. But there's a twist.

sex is considered a frill, something that is enjoyable to engage in, but certainly not necessary.

Frill? I consider it a fringe benefit.

There are lots of reasons that couples don't go to see a sex therapist when they run into problems--including embarrassment--but one of the biggest is the lack of insurance coverage.

Really?

"Gee honey, we really should see a sex therapist but my policy doesn't cover that."

That's pretty lame.

because of the lack of insurance, many such couples just fumble through these changes, often losing their sex life along the way. That’s one reason why so many older men go off in search of a mistress,

Across the Pond, they've taken to calling this "public services apartheid." Ouch.

In addition to the arthritis meds, there's a whole raft of cancer treatments available to Scotsmen but offlimits to the English. These include lung cancer treatment tablets, implants to fight brain tumors, and osteoporosis treatments.

The problem is exacerbated by the fact that Scotland receives some 11 billion pounds (almost $23 billion) in "financial aid" from London, which serves to stoke the flames of resentment.

According to the Congressional Budget Office American's are becoming increasingly co-dependent and less self reliant. It seems that, over the last 30 years at least, we have completely lost touch with reality.

We have been conditioned to think in terms of copays rather than actual costs of health care and we are paying dearly for that dependence.

We are willing to shift the responsibility for paying health care providers to the carrier.

Another important factor that both reflects and has contributed to rising health costs is the declining proportion of those costs that are paid out of pocket. Out-of-pocket payments accounted for 33 percent of all personal health care expenditures in 1975, but by 2005, that share had fallen to 15 percent

Thirty years ago individuals paid 33% of their health care needs out of pocket.

Today it is 15% and continuing to drop.

This co-dependence has got to stop. Relying on the carriers to "pay for" primary care is not going to solve anything and will only continue to make things worse.

rising health care costs (as a share of income) have probably led individuals to seek more extensive insurance in order to keep the variability of their out-of-pocket expenses from increasing.

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Tuesday, November 13, 2007

When completing an application for life insurance, one is required to answer all of the questions "to the best of one's knowledge."

One of the questions on ALL life insurance app's is: do you currently have any other applications pending (or words to that effect)?

So about a month or so ago, I get a call from Ben, who's looking to purchase some life insurance. He'd tried to do so this past summer, but was turned down by Company H due to "recent open heart surgery." Which would have made sense, except that (Ben claims) that he never had any such surgery, recent or otherwise.

In fact, he'd been in contact with Company H attempting to "set the record straight," but had had no success. I explained that this was not surprising: he needed to be working with the MIB, not the carrier. He and the Missus apparently appreciated my advice, and we went about completing his application with Company C. I also contacted our paramed service to schedule his exam (which was required due to his age and the requested face amount).

About 10 days ago, I received a note from the underwriter asking about a "plethora of activity" in Ben's MIB file. I reiterated the story of the non-surgery, and put the file aside, awaiting a decision.

Today, my Company C field rep called with an interesting development: it seems that they have received a second application for Ben, from another agent, for the exact same face amount and policy type.

Ooops.

Since my app had hit the home office first, I had dibs on the case, but they really wanted to know what was going on. I called Ben and got his voice mail; after leaving a message, I also called Mrs Ben and got hers, as well. This afternoon, Ben called back, said he was just trying to get a policy, and said he'd work with the other agent.

Not so fast, fella.

So I called my field rep back, and told him that I was not too happy about the whole situation: I had already spent considerable time, and helped resolve a problem that I hadn't even created (Company H's decline), and I wasn't too happy about just stepping aside. I also pointed out that Company C now had a major problem:

One of those two app's is fraudulent.

Hunh?

Well, let's go back to our initial stage-setting: depending on with whom he had first met, Ben lied to either me or the other agent. That is, he told us both that he had no other application pending. Since he couldn't have been at both places at the same time, one of those statements was a lie.

Now, I could agree to withdraw the app which I submitted, or the other agent could. But that would not obviate the fact that Ben had willingly and knowingly submitted a fraudulent application. And both to the very same carrier.

Had he submitted app's to two different carriers, it still would have constituted fraud (assuming the same facts), but it would be very unlikely to have been caught.

So, is Ben a fraudster, or a moron?

I have my own opinion, of course, but I'd really love to hear our readers'.

UPDATE (11/15/07): My field rep called late yesterday afternoon with more information. Turns out that my application did indeed hit the home office first, and was dated the 23rd. The other agent's app arrived a few days later, dated the 26th. While this serves to confirm my place as 1rst in line (a rather dubious distinction in this case), it also underscores something else: while it's certainly reasonable that one might forget a few stitches received 15 years ago, how does one forget completing another insurance application (not exactly the world's shortest form) three days before?

And there's this:

There has apparently been a lot of MIB activity on Ben in recent weeks, not all explained by the alleged error regarding the heart surgery. If I had to guess (and it is just a swag), I'd say ol' Ben's got more apps out there than just the two we currently know about.

Last spring, we reported on Paid Time Off Banks, where employees could treat their sick days as commodities. Of course, this was predicated on the assumption that employers voluntarily allot a certain number of those days.

But what happens when the gummint mandates that employers provide paid time off for illness?

Well first, as we've seen in every other area of the benefits equation, people will lose benefits (days).

Hunh?

Well, if the gummint mandates that employers must provide, for example, 8 such days a year, what employer would voluntarily offer any more than that?

Dr Anonymous hosts this week's edition of the venerable medblog roundup. I think the new "Top 10 and Then the Rest" model is becoming the "new normal" (although the Doc actually has a Top 5). "The rest" includes some 38 posts, so there's bound to be something to pique your interest.

We are major advocates of transparency in health care, so I especially liked this post at Running a Hospital. It's actually the personal blog of the "CEO of a large Boston hospital," which is pretty cool in itself. The CEO, Paul Levy, posts on his hospitals venture in publicy disclosing outcome rates for infections (and yes, it's a bit dated, but still relevant).

Just like we have exported fast food to foreign nations, now it seems that health care is moving in and taking root. Famous names like Johns Hopkins, Cleveland Clinic, Mayo, Duke and others are now "franchising" on foreign soil.

In a way it makes sense.

Just last month the original Maytag plant in Newton, Iowa closed its' doors. The dependable Maytag appliances will still be around but will be built in Mexico instead of Iowa.

If washing machines can be built in Mexico at a lower cost then why not hip replacements in India?

If Mexican workers can put the Maytag emblem on washers & dryers then why not Indian health care workers put the Harvard Medical International seal of approval on an artificial hip?

"It's not good enough any more to be the greatest name in American medicine," he says. "If one is truly going to be a global leader, [you] have to try to figure out how to work globally."

This is only a test. If it were real life, most people would make a failing grade.

The purpose of this test is to illustrate ways to make health insurance more affordable for the average consumer.

Our test family lives in a middle class zip code in greater Atlanta. The parents are early 40's with two children, including one of college age. Everyone is assumed to be healthy.

The family visits the doctor about 8 times per year and no one is on medication.

They are given achoice between two plans (out of approximately 1800) from a major carrier. These are not the most expensive nor the least expensive plans.

One plan is $393 while the other is $838.

The lower priced plan has no copays and a $5,000 deductible. The higher price plan has doc & Rx copays and no deductible.

Given the choice between these two plans, most consumers would opt for something similar to the higher priced plan, especially if money were no object. Even when they pay the full premium and all out of pocket costs themselves, most will opt for a variation of plan B over the other plan.

If their goal is to maximize total health care dollars, they failed the test.

Sunday, November 11, 2007

One of our local weeklies ran an article on the woes of our taxpayer funded, "charity" hospital. Grady Hospital has been in the news quite a bit over the last few years and even more so as they face a serious funding crisis.

While the issue of Grady is local, it is reflective of what ails many of the public supported hospitals in cities all across the country.

Too many non-paying patients.

He’s supposed to be on medication for high blood pressure, but hasn’t taken it in several months because lately he can’t afford it. He’s self-employed and, like many carpenters, roofers, plumbers, electricians, painters and contractors everywhere, he doesn’t have insurance. Fully 33 percent of Grady’s patients are uninsured.

There are many ways to control hypertension, including meds. Hypertension meds are among some of the lowest priced and many are on the $4 generic list at Wal-Mart & Target.

Additionally, there are programs available for those who cannot afford medication that allows them to receive their meds at little or no cost.

The problem with Grady is the same problem that would affect any business. When fully one third of your clients do not pay their bills any business would have a problem staying open.

I found this comment noteworthy.

some hospitals and health care systems, like Grady, are fighting for their lives, while private American health care systems open state-of-the-art hospitals overseas.

Overseas, the poor go to public hospitals, so the private American outfits cater to burgeoning middle classes—like India’s call center workers, who are provided insurance by their American employers.

Michael Moore must have missed this in his documentary.

the greatest irony of all may be how Medicaid, a national health coverage plan designed to pay for the care of those who cannot pay for it themselves, has become so overburdened and so politicized that even on its best day, filing for Medicaid reimbursement is a bit like playing the lottery

Ah yes, Medicaid. The other taxpayer funded health care system that politicians want to expand.

But much of what ails Grady (and perhaps other public hospitals as well) is poor management.

if an emergency room treats someone whose case is deemed by the CMOs not to be an emergency, the hospital is paid what is called a triage fee—only about $50, says Kevin Bloye of the Georgia Hospital Association—no matter how much time was spent with the patient or how much was done for him.

How many non-emergency situations are being treated at Grady (and other hospitals) where the reimbursement by the taxpayer is only $50?